Dietary transitions in African cities: leveraging evidence for interventions and policy to prevent diet-related non-communicable diseases (NCDs)

Abstract

Africa is currently experiencing rapid change partly driven by increasing migration of individuals to cities. Dietary habits are also changing with increasing consumption of unhealthy foods that are high in calories and low in nutrients. Such changes have resulted in increasing levels of obesity in cities, with rates higher for women. Policy responses have been limited in success so far, and are mostly influenced by experiences in higher income countries which are less relevant to African cities. There is also less understanding of the factors that drive food consumption in Africa, particularly the role that people's social networks play (e.g. family or peer groups) and the neighbourhoods that individuals live in (e.g. access to fast food outlets). There is a need for stronger evidence that accounts for the environments that people live in to inform strategies to promote healthier food consumption in African cities.

Our project will explore the factors that are associated with food consumption patterns (what people eat) and practices (how, where, when and with whom they eat) within two African cities (Nairobi and Accra). We will undertake novel approaches for collecting data on food consumption and practices, and the factors associated with them. The different approaches will use both existing scientific evidence as well as including the views of local people and stakeholders in identifying solutions to the problem of eating poor quality high calorie diets. These will include: reviewing the state of knowledge throughout published research and analysing existing information on dietary behaviours; interviewing people about what kinds of food they eat and how they eat it (e.g. in a hurry, alone or with others) and using photography with local people to explore the factors that influence these decisions. We will also be mapping the food environment in people's neighbourhoods (e.g. location and type of food outlets available) to explore how characteristics/features in the environment might influence people's food consumption and practices. Based upon the results of this, we will be able to identify the range of factors that are associated with dietary patterns and practices. We will then compare these factors to current policy approaches in these settings to assess which gaps may require addressing and identify interventions with local experts and policy makers that may be useful to do so.

The proposed research will strengthen existing partnerships and build new ones, enhancing capacity in research, thereby paving the way for development of new interventions that are more likely to be effective. Our results will then be shared more widely with experts and policy makers from similar African cities via webinars, social media and regular updates on our project website. This will help them design effective strategies to improve dietary patterns and practices to tackle obesity.

Technical Summary

Our project investigates the changing food and nutrition environment in the context of rapid urbanisation in Africa. The overall aim is to explore food consumption patterns and practices and the factors associated with them in two African cities (Nairobi and Accra). The project is divided into three interrelated work packages. Workpackage 1 will synthesise evidence on current food consumption patterns and practices and explore their social and physical determinants. It will gather all known secondary data on food consumption patterns and practices for the two countries and undertake a meta-analysis of demographic and social correlates of these. A systematic review will be undertaken to explore the current state of knowledge regarding the factors influencing food consumption patterns and practices in urban Africa.
Mixed methods data collection will be undertaken including a 24-hour recall to collect information on food consumption and practices. This will be combined with a Photovoice exercise to examine which social and physical factors influence participants' food consumption. This will be supplemented with spatial data on the features of participants' neighbourhoods that may influence food consumption. Findings will be synthesised into a framework map of the factors that influence food consumption in these two African cities.
Workpackage 2 will develop context-appropriate policy. It will examine the current range of policies in each country, and explore how they relate to our framework map. We will produce guidelines for encouraging healthy diets and review what interventions could be implemented using a realist literature review to identify what could works in these contexts, resulting in a policy brief detailing potential interventions.
Workpackage 3 will focus on knowledge translation and disseminating findings to key policy makers and the public. It will involve a photography exhibition based on workpackage 1, as well as national stakeholder meetings.

Planned Impact

ODA justification:
This study involves a multidisciplinary team comprising UK and LMIC investigators from 2 partner countries. Kenya is listed under 'other low income countries' on the DAC list of ODA recipients, and Ghana is a lower middle income country. Both countries are experiencing rapid urbanisation, leading to changes in food consumption patterns. Such changes are associated with an increased prevalence of diet-related non-communicable diseases (NCDs). Health policies, including dietary guidelines, have not kept up with this rapid pace of change. Mortality from NCDs is increasing in both countries and is likely to hinder future economic development through increasing costs of healthcare. Both partner countries, in consultation with their Ministries of Health, have identified the need for national food-based dietary guidelines and the development of context-specific interventions to prevent diet-related NCDs. This research is important to the welfare and future health of the populations in these two countries; particularly among socio-economically disadvantaged groups which are experiencing the greatest increase in overweight/obesity. The research is also relevant for other African countries that are following similar trajectories of rapid urbanisation and dietary change. The major impact of this study will be to identify interventions to promote healthy diets to prevent diet-related NCDs, adapted to these contexts and to the lives of adolescents and adults. By focusing on environments that drive unhealthy food consumption, emerging interventions will benefit the whole community, thereby positively impacting on development. Well-nourished populations have better capacity for cognitive development and participation in the labour market, which also positively impact on development.

Beneficiaries of the research include:
1) The adolescent and adult participants in Accra and Nairobi who take part in the photovoice activities and the opportunity to express a voice through the exhibition portraying their personal food environments. We will thereby empower the local community with the capacity of using photography to influence change in the nutrition environment in their communities. 2) Community leaders (e.g. community health workers, village elders, community group leaders, local NGOs) who engage in the dissemination workshops of the overall findings of this exercise. 3) Local, national and regional stakeholders (eg nutrition units in the ministries of health and agriculture, WFP, WHO, FAO regional office, Federation of African Nutrition Societies, IFPRI, Scaling Up Nutrition knowledge networks/academic platforms) who will be engaged in the project from inception through consultative meetings at critical points of the study, including before and after policy mapping; in preparation for evidence synthesis, and throughout knowledge translation. Findings from the study will also be disseminated to policy and decision makers (internationally, nationally and locally) through factsheets, policy briefs, blogs, and through various institutional websites. 4) Academic researchers in LMICs and globally will benefit from the research through the dissemination of project findings at international conferences, scientific publications and capacity building activities. At the heart of our team's vision is capacity building, particularly for early career researchers. We will include young researchers in the project team, including postdoctoral researchers. We will facilitate a workshops to allow sharing of academic knowledge and learning from the different institutions involved in the research team including early career and senior researchers. 5. Advocacy groups including human rights activists and the media are likely to use the evidence generated from this study to advocate for review of policies and guidelines in the relevant ministries and county governments, and practices among nutrition and health stakeholders.

Publications

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Title Photography booklet from Kenya 
Description A Photography booklet was produced to accompany the photographic exhibition in Kenya 
Type Of Art Image 
Year Produced 2018 
Impact The booklet was shared with participants at the exhibition. 
 
Description Growing urbanisation in Africa is accompanied by rapid changes in food environments, with potential shifts towards unhealthy food and beverage consumption. This study investigated how eating practices and routines in African cities shape unhealthy food/beverage consumption, to be able to identify context relevant policy. Deprived neighbourhoods in two African countries (two Ghanaian cities and one Kenyan city) were investigated A structured meal pattern of three main meals a day with limited snacking was evident. There was widespread consumption of unhealthy foods. However, consumption of traditional foods that are full of nutrients but also calories was also common: >84% of the sample consumed these in both countries. Low socio-economic groups were more likely to consume unhealthy foods. Most eating episodes were quick: <30 minutes for 87.1% of Ghanaian respondents and 72.4% of Kenyan respondents. Families and the home environment were important: >77% of eating episodes were consumed at home and >46% with family, which tended to be energy dense. Eating alone was also common as >42% of eating episodes were taken alone.
Rather than repeating existing large scale population surveys, we synthesised evidence from 47 population studies (20,726 individuals) and undertook a meta-analysis to examine the healthiness of dietary behaviours relevant to nutrition transition among adolescents/adults of 2 African countries (Ghana and Kenya). We found indications of nutrition transition: consumption of fruit and vegetables was low (51.6% consumed). Sugar-sweetened beverages were consumed by >1/3rd of populations (39.9%). Consumption of animal-source proteins was widespread (68.8% consumed). Evidence was lacking on eating out. Promoting consumption of fruit/vegetables and reducing sugar-sweetened beverages could be targets for interventions. We also undertook an audit of food outlets and advertisements in: Jamestown, Accra; Ho Dome, Ho (both Ghana); Makadara, Nairobi (Kenya). A wide diversity of foods was reported, with high availability of healthy (e.g. staples, vegetables) and unhealthy foods (e.g. processed/fried foods, sugar-sweetened beverages). Almost half of advertisements were for sugar-sweetened beverages (48.3%), with high exposure to alcohol as well (28.5%). Support for advertising controls by government was evidenced in our stakeholder dialogues in Ghana that explored implementation and priorities for policy and interventions to improve food environment. However, this was not the case in the stakeholder dialogue in Kenya, where nutrition standards, health claims and food labelling were the top priorities.

Policy action to prevent obesity and related diseases and ensure micronutrient coverage is required across several sectors: including support for local food vendors. Actions to limit access to unhealthy foods through subsidies and advertising policies to dis-incentivise unhealthy food consumption, especially sugar-sweetened beverages. Introducing dietary guidelines incorporating advice on reducing fat in traditional foods accompanied by cooking skills interventions focussing on reducing frying/oil used when preparing traditional foods and reducing the sugar content of breakfast.
Exploitation Route A National Nutrition Policy Forum has been established in Ghana that launched on January 21st, Accra, Ghana. We presented the findings of our project here and the policy forum was set up partly in response to our project's activities
Sectors Agriculture, Food and Drink,Healthcare

 
Description The development and delivery of a new Masters level nutrition module on Nutrition in the global south (15 credits)
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact The new module is taught to around 26 Masters students at the University of Sheffield on our masters programme in Human Nutrition. These students can register as Associate Nutritionists after successfully completing the course, therefore contributing to the development of the nutrition profession.
URL https://www.sheffield.ac.uk/oncology-metabolism/masters/humannutrition/modules
 
Description Confidence in Global Nutrition and Health Research
Amount £176,472 (GBP)
Funding ID MR/R019657/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2018 
End 02/2019
 
Description HEFCE ODA Quality Research allocation 2017-18 call
Amount £21,099 (GBP)
Funding ID X/155293 
Organisation NIHR/HEFCE Higher Education Fund for England 
Sector Public
Country United Kingdom
Start 01/2018 
End 07/2018
 
Description New strategies to reduce anaemia and risk of overweight and obesity through complementary feeding of infants and young children in Peru
Amount £582,398 (GBP)
Funding ID MR/S024921/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 04/2019 
End 04/2022
 
Description ScHARR research stimulation fund
Amount £2,000 (GBP)
Funding ID unknown 
Organisation University of Sheffield 
Sector Academic/University
Country United Kingdom
Start 02/2018 
End 07/2018
 
Description UK-Africa network to improve the nutrition of infants and young children living in poverty (NINO LIP) in urbanising subSaharan African countries
Amount £176,472 (GBP)
Funding ID MC_PC_MR/R019657/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2018 
End 02/2019
 
Title 24 hour recall data 
Description in Kenya: 24 hour recall data for n=144 subjects (72 males; 72 females aged 13 years upwards) 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact So far the database has been created from collected data and has been used to identify unhealthy foods, such as energy dense nutrient poor foods. 
 
Title Photovoice data and qualitative interview transcripts in Kenya 
Description The qualitative interview transcripts and photographs from interviews with n=48 males and females in Kenya 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? No  
Impact The data were used to inform the development of the photography exhibition in October 2018 
 
Description Collaboration with APHRC 
Organisation African Population and Health Research Center
Country Kenya 
Sector Academic/University 
PI Contribution I am the project coordinator for the TACLED project and this collaboration is integral to that project. We have contributed to the collaboration by training the partners in a range of research methods, including Photovoice, 24 hour dietary assessment, evidence synthesis methods, GIS mapping, framework development. We also coordinate the overall project, ensuring everyone meets deadlines and that ethical and data management processes are adhered with.
Collaborator Contribution The partner has organised fieldwork and the collection of primary data. They have also participated in the teams for 3 different reviews. They have participated in delivering some of the training to the partner in Ghana
Impact The collaboration is ongoing and we do not have any outputs yet
Start Year 2017
 
Description Collaboration with the University of Ghana 
Organisation University of Ghana
Country Ghana 
Sector Academic/University 
PI Contribution I am the project coordinator for the TACLED project and this collaboration is integral to that project. We have contributed to the collaboration by training the partners in a range of research methods, including Photovoice, evidence synthesis methods, GIS mapping, framework development. We also coordinate the overall project, ensuring everyone meets deadlines and that ethical and data management processes are adhered with.
Collaborator Contribution The partner has organised fieldwork and the collection of primary data. They have also participated in the teams for 3 different reviews. They have participated in delivering some of the training to the partner in Kenya (APHRC)
Impact Multidisciplinary as the partners are public health specialists and they are partnering with us, which includes nutritionists and evidence synthesis experts.
Start Year 2017
 
Description INFORMAS collaboration 
Organisation University of Auckland
Department Faculty of Medical and Health Sciences
Country New Zealand 
Sector Academic/University 
PI Contribution We organised for the co-ordinator of the INFORMAS (International Network for Food and Obesity / non-communicable Diseases Research, Monitoring and Action Support) network to undertake some training for us and partners in this project on using the Food-Epi tool in one of the work packages. This has led to us being invited to join the INFORMAS network, which is a global network of public-interest organisations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity and non-communicable diseases (NCDs) and their related inequalities.This involves participation in regular skype calls to network across participating countries and also to be invited to participate in an INFORMAS network workshop in October 2017 in Argentina after the International Congress of Nutrition.
Collaborator Contribution The co-ordinator of the INFORMAS (International Network for Food and Obesity / non-communicable Diseases Research, Monitoring and Action Support) network travelled to Ghana in September 2017 and undertook a week of training for us and partners in this project on using the Food-Epi tool.
Impact The work is ongoing so we do not have outcomes to report as yet
Start Year 2017
 
Description Loughborough University 
Organisation Loughborough University
Department Centre for Global Health and Human Development
Country United Kingdom 
Sector Academic/University 
PI Contribution We are a member of the review team for WP1.1 systematic review of urban food patterns/practices and we are overseeing the fieldwork for WP1.3.1 the Photovoice method.
Collaborator Contribution Loughborough University is a collaborating partner in this project, leading workpackages on: WP1.1 systematic review of urban food patterns/practices and WP1.3.1 the Photovoice method. Their role was to offer training in these methods and coordinate the tasks.
Impact No outputs yet as these are forthcoming
Start Year 2017
 
Description Peru infant feeding collaboration 
Organisation Nutritional Research Institute
Country Peru 
Sector Private 
PI Contribution As a result of our group presenting our preliminary findings of our evidence at a meeting in Peru we were invited to become part of a collaboration with Peruvian partners to apply to the MRC/CONCYTEC Newton call on nutrition in Peru. Emily Rousham from our network led this application and it was succesfully funded. We (Emily Rousham, Paula Griffiths, Michelle Holdsworth, Rebecca Pradeilles and Emma Haycraft from the NINO LIP network) are now working in collaboration with Peruvian partners to support programming for double duty actions targetted at infants aged 6-23 months to reduce anaemia and overweight.
Collaborator Contribution We bring our global knowledge on community based interventions to improve infant nutrition to the collaboration. We also introduced design experts that we have been working with on other projects to the Peruvian team. We have expertise in social sciences which provide expertise in understanding context, psychology which supports understanding of supporting of infant feeding behaviours such as fussy eating as well as responsive feeding, nutrition which supports appropriate advice and intervention for infants of this age as well as assessing diet, nutrition policy which supports understanding of the policy environment which we can leverage and biological anthropology which drives knowledge on appropriate assessment of outcomes.
Impact MRC/CONCYTEC Newton award £1.06million entitled; "New Strategies to reduce anaemia and overweight/ obesity among infants and young children in Peru." Funded April 2019-April 2022. The collaboration is multi-disciplinary including: Social Sciences (Demography), nutrition, anthropology, psychology, biological anthropology and social anthropology.
Start Year 2018
 
Description University of Liverpool 
Organisation University of Liverpool
Department Department of Geography and Planning
Country United Kingdom 
Sector Academic/University 
PI Contribution We have supervised the collection of data on mapping the food environment with GIS (Geographical Information System), ensuring that this was collected in compliance with standard protocols.
Collaborator Contribution The partner trained the project team in mapping the food environment with GIS (Geographical Information System) and has coordinated the subsequent analysis.
Impact none yet
Start Year 2017
 
Description Dietary transitions in African cities. Stakeholder consultation event Nairobi 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We ran a workshop on the Key findings from the TACLED study. Dietary transitions in African cities. Stakeholder consultation event. 23rd May, Nairobi, Kenya. (>45 participants)
Year(s) Of Engagement Activity 2018
 
Description Implementing the Healthy Food Environment Policy Index (Food-EPI) module of INFORMAS in Kenya 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We organised a workshop on 26th July 2018 in Nairobi, Kenya. During the workshop, the extent of implementation of food environment policies in Kenya was assessed and priority actions were identified for the government to implement, with its partners, to create healthier food environments. Methods based on the Healthy Food Environment Policy Index (Food-EPI) by INFORMAS (International Network for Food and Obesity/NCDs Research, Monitoring and Action Support) were used. As part of the process, a panel of 14 local experts rated the extent of government action against international best practice ('high', 'medium', 'low' or 'very little') and against a within country planning and development cycle ('initiation', 'in development', 'implementation' or 'evaluation'). Actions for the government to implement to improve food environments in Kenya were proposed and prioritised.
Year(s) Of Engagement Activity 2018
 
Description Photovoice exhibitions 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact We organised a Photography exhibition in Nairobi, Kenya on October 30, 2018 in Jericho Social Hall, Makadara community.

The exhibition included the findings from the Photovoice work we had undertaken in an urban poor area (Makadara community). The exhibition was very well attended by the local community and there was a good discussion of findings with community members, local leaders and policy makers.
Year(s) Of Engagement Activity 2018
 
Description Stakeholder deliberative workshop in Ghana 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact A deliberative workshop was organised on 29th January 2019 to share the project findings in Ghana and discuss their implications with participants.

There was good attendance from a range of stakeholders including government, non-government and UN agencies. Many of the attendees had been there from the start of the project, which shows great commitment. . Attendees included lUniversity lecturers, who have since requested contributions from our work in their lectures. Journalists attended the event and publicised it in the local language and English in the Ghanaian electronic and print media. At least 7 occurrences have been noted including 2 audio transmissions in the local language as well as newspaper articles.
Year(s) Of Engagement Activity 2018
 
Description Stakeholder engagement event in Ghana 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact This was a formal Stakeholder engagement event in Ghana, organised by our partner (University of Ghana). It involved an overview of the purpose of the funded project and how it could contribute to improving the nutritional situation in Ghana, working alongside existing . It included discussion and debate of how the different stakeholders could contribute and get involved and how we would inform them of our progress throughout the project. It involved discussion about the steps for developing the food based dietary guidelines and how the different stakeholders could get involved, and identifying the gaps that are needed to move the development of such guidelines forward.
Year(s) Of Engagement Activity 2017
 
Description Stakeholder engagement meeting in Kenya 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact This was a formal Stakeholder engagement event in Kenya, organised by our partner (APHRC) to coincide with the project's kick off meeting. It involved an overview of the purpose of the funded project and how it could contribute to improving the nutritional situation in Kenya. It included discussion on debate of how the different stakeholders could contribute and get involved and how we would inform them of our progress. This included discussion on development of national dietary guidelines and how we can work together to develop food based dietary guidelines.
Year(s) Of Engagement Activity 2017